CommercialPrior AuthHigh impact
Positron Emission Tomography (PET) Oncologic Applications 6.01.29
Excellus BlueCross BlueShield·NY · Oncology, Radiation Oncology, Radiology +1 more·Radiology (x-rays) & Imaging
Effective date
May 15, 2026
We identified it
Jul 16, 2026
Summary
Excellus BlueCross BlueShield has updated its PET Oncologic Applications policy (6.01.29) effective May 15, 2026, establishing new medical necessity criteria for FDG-PET and PET/CT imaging across 25+ cancer types. The policy defines when PET imaging is appropriate for initial staging, restaging/recurrence, and surveillance, with specific clinical criteria for each cancer type. Billing teams must align claim submission and prior authorization processes to match these detailed eligibility requirements by the effective date.
Action Required
By May 15, 2026: Billing team must implement the following changes: (1) Update billing system and prior authorization workflows to enforce cancer-type-specific PET imaging criteria as outlined in policy 6.01.29; (2) Configure system rules to deny or require medical review for PET claims that do not meet stated criteria (e.g., surveillance PET in asymptomatic patients, advanced imaging for DCIS/LCIS without symptoms); (3) Create or update claim submission templates/checklists requiring providers to document clinical indication (initial staging, restaging, recurrence, surveillance) and whether conventional imaging was non-diagnostic or inconclusive; (4) Implement prior authorization requirements for all PET oncology claims submitted to Excellus BlueCross BlueShield; (5) Train billing, coding, and clinical staff on the 25+ cancer-type-specific criteria detailed in the policy; (6) Update encounter forms and EMR templates to capture required clinical documentation elements (cancer stage, conventional imaging results, clinical indication). Claims submitted without proper clinical justification and prior authorization aligned to the policy criteria will be denied by Excellus BlueCross BlueShield.